As an IVF specialist, I receive a lot of queries from infertile couples from all over the world. Many of these are older couples who have been infertile for many years; and since they cannot get medical treatment in their own countries ( either because it’s too expensive or because their government does not allow it), they want to come to India for treatment. Many of them think that because they are too old, their best option would be surrogacy; and since they have read many articles about how easy surrogacy is in India, they often email me asking for gestational surrogacy services.

The tragedy is that so many infertile couples are still so poorly informed about surrogacy treatment and who it is useful for. Many couples naively believe that a surrogate is the final answer to all infertility problems; and that surrogacy has a 100 % pregnancy rate ! Sadly, this is just not true !

Surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus, or whose uterus is damaged. Older women who are infertile rarely need a surrogate. As they get older, their fertility declines, not because their uterus ages, but because their eggs get old – a condition called the oopause. Since their own uterus is usually completely normal, using a surrogate makes no sense for them at all ! After all, how can replacing a normal uterus (their own) with a surrogate’s uterus improve pregnancy rates just because the surrogate is fertile and has had babies in the past ? These couples would be much better off considering the options of donor eggs or donor embryos.

Unfortunately, they are often so desperate to have a baby, hat they do not bother to learn that as their biological clock ticks away, it’s the ovaries which get depleted of eggs – not their uterus. Since surrogacy is a lucrative treatment option to offer ( it’s the most expensive of all the IVF treatments offered today) , many IVF clinics are happy to offer surrogacy, without bothering to explain to couples why it may not be the right treatment option for them.

It’s exactly the same situation with couples who have failed multiple IVF cycles; or who have had repeated miscarriages. They are emotionally very vulnerable and are willing to clutch at straws. They have low self-esteem, since their bodies have failed them, and are very happy to explore surrogacy. However, research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem. Even though surrogacy may not be their right treatment option for them, it continues to be overused and misused. This sort of medical abuse it likely to give all IVF clinics a bad reputation.

Infertile patients expect that their doctors will provide them with treatment to improve their chances of having a baby. Tragically, some medical procedures can actually end up reducing your fertility !

Here’s a list of the top ten procedures which can actually harm you, rather than help you ! If your doctor advises any of these, please get a second opinion before agreeing !

1. D&C ( dilatation and curettage) . This is a “minor” surgical procedure in which the doctor dilates the mouth of the uterus ( the cervix) and scrapes the uterine lining using a curette
( curettage). This endometrial tissue is then sent for pathological examination. In the past, when doctors had very little to offer to their patients, this used to be the mainstay of the treatment of an infertile couple. In fact, even today, some women will ask the doctor to do a D&C for them because their mother conceived after doing this procedure ! They feel that it helps to “clean the uterus”, thus improving their fertility ! While it is true that some women will get pregnant after a D&C ( sometimes this is just a placebo effect; while sometimes the endometrial inflammation induced by the procedure can improve uterine blood flow and fertility), this is an obsolete procedure which should be used in this day and age only for confirming the diagnosis of endometrial tuberculosis.

2. Metroplasty. This has become quite a fashionable procedure in some parts of India, where the doctor “improves” the shape of the uterine cavity to improve fertility. It can actually create uterine scarring and induce fertility. It’s only in India that doctors use this technique for “treating” infertility. In all other countries, it is reserved for correcting uterine anomalies or removing intrauterine adhesions.

3. Hydrotubation. This is a procedure in which the doctor flushed the uterus and the tubes with fluid ( which often contains a concoction of chemicals such as steroids and antibiotics) to treat infertility. While it can help some women with cornual blocks, for the vast majority this painful treatment ( which is often repeated many times in one month) is a waste of time and money.

4. Empiric treatment for abnormal sperm . This continues to remain a major time-waster for infertile couples. Tragically, most doctors are still unaware of the recently revised criteria of what a normal sperm count is – and will often reflexively treat men with what they think is an “abnormal sperm report”. There are various levels of sophistication to this futile effort. To cloak this with an aura of scientific respectability, high tech labs will now test sperm for DNA fragmentation levels – and doctors are quite happy to “fix” the problems these tests will often pick up. What many patients do not realise that there is very little correlation between these test results and their fertility potential – and that even fertile men have high DNA fragmentation levels ( but are fortunately unaware of this, as they have enough sense not to get their sperm tested in a lab !)

5. Treatment for genital tuberculosis. We are now seeing an “epidemic” of uterine TB in India – especially in north India, where it appears that practically even woman who goes to a gynecologist has TB ! Doctor use dodgy tests called PCR to test the endometrium for the presence of DNA fragments which are supposed to be be specific markers for the tubercle bacilli – without even bothering to determine what the prevalence of this TB PCR positivity is in the fertile population ! Not only do these poor patients end up taking 6 months of toxic and expensive drugs; their husbands will often stop having sex with them ( because they are worried that they will transmit the TB to them); while others are scared that they will give the TB in their uterus to their baby !

6. Treatment for TORCH infections. Women who have been unfortunate enough to have a miscarriage will get routinely ( and mindlessly) tested for the presence of antibodies against the TORCH group of infections. If any of these tests is positive, the doctor then promptly treats this infection with antibiotics ( which are completely useless and uncalled for !). The truth is that pregnancy. You can read about this at http://www.drmalpani.com/torch.htm

7. IUI ( Intrauterine insemination ) for treating couples men with a low sperm count. Since everyone knows that ” you need just one sperm to fertilise an egg”, it seems to make a lot of sense to treat infertile couples who have a low sperm count with IUI . After all, IUI is a simple and inexpensive treatment, which every gynecologist can offer – and patients understand the logic as to why it should help. The truth is that the problem with men with low sperm counts is not just that their sperm count is low – its often that the sperm are functionally incompetent – and no amount of concentrating the good sperm or washing them is going to help !

8. Diagnostic laparoscopy. Once upon a time, a laparoscopy was a major advance in evaluating the infertile woman, because it actually allowed the doctor to visualise the ovaries and fallopian tubes without having to cut open the patient ! Minimally invasive surgery was a major advance then , but now it’s being overused. Many doctors still routinely perform a laparoscopy for all infertile women, which is completely unnecessary surgery, as is does not change the therapeutic options for these patients. The status of the fallopian tubes can as easily be checked with a simple HSG, which is much less expensive ! It’s true that a laparoscopy allows the doctor to also “find” adhesions and endometriosis, but making the diagnosis of this ( or “treating” them ) does not really improve the patient’s fertility at all !

9. Medications for treating endometriosis. Endometriosis is an enigmatic and frustrating disease; and mot doctors will still reflexively “treat ” this with medications, such as GnRH analogs. While these medications are great at suppressing the endometriosis (and will provide dramatic pain relief), this suppression is only temporary – and does not improve the patient’s fertility at all (since they also suppress ovulation at the same time !) Once the meds are stopped, the endo recurs ! Even worse, “treating” the endo with meds just wastes the patient’s time – something which most infertile patients cannot really afford to fritter away !

10. Operative laparoscopy for myomectomy and cystectomy. One problem with today’s high tech diagnostic tools ( such as vaginal ultrasound scans) is that it allows the doctor to “diagnose” small 1 cm size ovarian cysts and fibroids. Now while cysts and fibroids are very common in fertile women as well; and small cysts and fibroids do not affect fertility, once the sonographer has “reported” his “diagnosis”, the patient often panics ! The doctor is happy to point out these abnormalities – and convinces the patients that it is these abnormalities which are the cause of her infertility – and that once these are “treated”, she’ll get a baby quickly ! What’s worse is that it’s easy to do the surgery with a laparoscopy ( which is just “minor surgery”), that patients are quite happy to sign on the dotted line without realising that these are incidental findings of no clinical importance; and that the surgery will not help them. What’s worse, is that this unnecessary surgery can reduce your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

I sometimes think we are seeing an epidemic of overtesting and overtreatment. Doctors seem to like doing tests – and patients like being tested ! Unfortunately, patients are still not sophisticated enough to differentiate between useful tests and useless tests – and the truth is that some tests can actually be harmful !

The hidden danger with a lot of these unnecessary testing is that patients get fed up; lose confidence in doctors; and refuse to pursue more effective treatment options, because they do not trust doctors any more !

Dr. Aniruddha Malpani is one of the best Infertility Specialists in India. He completed his MBBS from Seth GS Medical College, Bombay, in 1982. He took his DGO and MD degrees from Bombay University. He passed his D.N.B. appearing for the National Board of Examinations. Dr. Malpani has been the recipient of a glittering array of prizes, awards and scholarships through his academic years.

Currently, he and his wife Dr. Anjali Malpani, both infertility specialists, are in private practice.

Dr. Aniruddha and Dr. Anjali Malpani have started India’s first Sperm Bank in Bombay, for therapeutic insemination by using donor cryopreserved sperm The Bank has a full-fledged infertility unit, which provides comprehensive services, including IVF, GIFT and micromanipulation. The doctors have achieved the first pregnancy in India using the sophisticated technique of PGD (preimplantation genetic diagnosis), which allows a screening of embryos for genetic abnormalities. They have also started India’s first support group for infertile couples, a registered charitable trust, called Infertility Friends.

Dr. Malpani believes in empowering the public with health awareness, as a means of promoting its health, and helping itself prevent and treat ailments in partnership with doctors. He has founded the Health Education Library for People, India’s first Consumer Health Education Resource Centre with reading, browsing and other library facilities. It has a collection of books, magazines, journals, CD ROMs, and videotapes covering all aspects of health explained in terms, which the lay person can understand.

Dr. Aniruddha has, with Dr. Anjali Malpani, authored two books: Getting Pregnant – a Guide for the Infertile Couple, and Best Medical Care – A Guide for the Intelligent Patient. He has published articles in several national and international journals. Memberships: He is a member of the European Society for Human Reproduction and Embryology, Brussels, Belgium.

Most patients find that one of the most difficult things to manage during an IVF cycle is the dreaded 2 week wait ( 2ww) after the embryo transfer. Time seems to come to a halt and you live in a state of suspended animation – a bit like Schroedinger’s cat ! Am I pregnant ? Am I not pregnant ? Every ache and twinge sends you scurrying to the bathroom to check if your periods have started – and you over-interpret every signal your body sends you. Am I feeling nauseous ? Is this a good sign ? Do my breasts feel fuller than usual ? Is this just PMS ? You try to prevent your mind from playing games with you, but this is surprisingly hard to do. Every hour seems to stretch on like a day ! You obsessively compare notes with all your online IVF friends – and drive your husband batty with your interpretations and wild imaginings ! Every time he drives the car through a pot-hole, you go bonkers with the anxiety that the jolt has jarred your embryos out of their safe uterine haven and caused them to fall out !

Why do I have to wait 12 days after the embryo transfer to do a pregnancy test ? Can’t I do it earlier ? After all, if I am pregnant, won’t the test show this ? Aren’t the new tests very sensitive ? Aren’t they supposed to show a positive result even before the period is missed ?

You cheat and start doing pregnancy tests anyways – how can it hurt ? And every time it’s negative, you still hope against hope ! Maybe I did it too early ? Maybe it will show up as positive if I wait another 2 days ? How can God be so unfair ? After all the shots I have taken and the pain I have suffered, I am sure he will not let me down and will give me my baby !

Remember that your embryos are safe in your uterus and that nothing you do can harm them ! If they are going to implant, they will and there’s precious little you can do to influence the inefficient biological process of embryo implantation either way.

Continue taking all your medicines; leading a normal life; and please remember the Serenity Prayer.

God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.

While all IVF patients understand with their heads that not every IVF cycle results in success, in their heart of hearts, every patient expects to get pregnant every time they do IVF ! This is why the 2ww after the embryo transfer can be so nerve-wracking ! Am I pregnant or not ? Have the embryos implanted or not ? The suspense during the 2ww can be even worse than the pain of the IVF injections !

Most patients would love to have a test which will allow them to find out if they are pregnant immediately after the embryo transfer ! Have the embryos stuck or not ? Why can’t we do a pregnancy test and find out right now ? Even if I am not pregnant, at least it’s better to know than to be unsure.

To understand why patients ( and their doctors ) still have to suffer through a 2 week wait to find out the outcome of an IVF cycle, let’s look at the biological basis of pregnancy tests and how they work.

A pregnancy test measures the amount of beta hCG ( human chorionic gonadotropin) that is in your body. HCG is a hormone which is produced by the trophectoderm cells of the embryo. It is produced in detectable quantities only after the embryo implants. Since implantation occurs 3 – 8 days after the embryo transfer ( depending upon whether you have had a Day 3 transfer or a blastocyst transfer), this means that the HCG produced by your embryo will be first detectable in your bloodstream only after this time.

As your pregnancy progresses, the amount of hCG in your system will increase. At 10 days past ovulation ( DPO) , for example, the average woman has an hCG measurement of around 25 mIU. This amount doubles to 50 mIU at 12 days past ovulation, and then doubles again to 100 mIU at around two weeks past ovulation. Every woman’s body is different, and there’s a lot of variation in HCG levels from woman to woman !

Home pregnancy tests measure the level of HCG in urine. Different pregnancy tests have different levels of sensitivity which means if you use a home pregnancy test that is sensitive to 100 mIU, it will not tell you that you are pregnant if your level of hCG is only 75 mIU. These tests cannot measure a level lower than 25, so they do not become accurate until a few days after embryo implantation. A negative result before then is meaningless, since there would not be a high enough level of HCG to detect even if you were pregnant. If your test is negative, you should retest after 2 days. This is why taking a pregnancy test too early can lead to inaccurate results. I know it’s hard to wait those extra days and you may want to try much earlier. It’s fine to do this, but please don’t assume that a negative results means that you are not pregnant.
This is also why blood tests for HCG are much better than urine tests. Not only are they more reliable, accurate and sensitive, they also give the doctor a number which he can measure and monitor.

If blood tests are so sensitive, then why not do a blood test for HCG 1 week after the embryo transfer ? Unfortunately, doing a blood test for HCG so soon does not make any sense. This is because there will still be some HCG in your body as a result of the HCG trigger shot ( Choragon or Ovidrel) which the doctor gave you to trigger off ovulation 36 hours prior to egg collection. If you test too early, the test will always be positive, as this HCG will show up in the test and give rise to false hopes ! This is why the doctor needs to repeat the blood test for HCG after 48-72 hours. In a healthy pregnancy, the HCG levels will continue to rise. If they do not do so, this means this is not a viable pregnancy.

Finally, remember that you should do the test even if you bleed. Bleeding can sometimes occur during pregnancy as well – and just because you have had bleeding or spotting does not mean you are not pregnant !

The commonest question patients will ask before starting an IVF cycle is – what are my chances of getting pregnant ?

While it’s true that the chances of success do depend upon how good your IVF clinic is, it’s also true that the chances do depend upon biological factors which are outside your control – the most important one of which is your age !

You can now use the Free IVF Predictor to estimate how good your chances of success are ! While you cannot do much about your age, you can improve your chances of success by choosing a world class IVF clinic !

Probably one of the most enjoyable books I’ve read on infertility is: A Few Good Eggs: Two Chicks Dish on Overcoming the Insanity of Infertility by Julie Vargo and Maureen Regan. This guide is actually targeted to infertile women residing in the US, and it is designed in the currently fashionable “chick-lit” style. It’s amusingly put together; and it is certainly a breath of healthy air, if you are the type of individual who discovers a sense of humor can help you deal much better with infertility.

This book is loaded with lots of Top-10 lists, and here is their valuable listing of Top 10 Myths Regarding Infertility:

10 Mis(sed)-Conceptions Regarding Infertility

1. Infertility will not happen to me.
2. I cannot be infertile. I already have got a child!
3. I can easily conceive, therefore i do not have fertility problems. I basically have miscarriages.
4. I am just too young to possess fertility problems!
5. My physician shared with me that i don’t need to visit any fertility expert unless I have 3 miscarriages.
6. I am fit. I work out on a regular basis. I cannot become infertile.
7. I am certainly not infertile. I am just not having good enough sex.
8. A person can easily wait a long period to have a child.
9. Males cannot be infertile. They produce sperm regularly.
10. Normal is a miracle.

Below are my remarks on this list:

1. Infertility will not happen to me.

This really is wishful thinking. The unfortunate truth is that the inability to conceive is a common problem which affects around one in ten couples. This means your likelihood of being infertile is around 10%. Sadly, there isn’t any trustworthy technique of being able to check your own fertility (short of really conceiving a child!). There isn’t any sign or indication or hint that will tip you off that you may be infertile. That is why numerous couples are “pre-infertile” – they get worried (often unnecessarily) as to whether they might have issues conceiving when they fail to get pregnant the very first month they attempt to have a baby!

2. I cannot be infertile. I have already got a child!

I’m sorry. As economic consultants tend to be so keen on reminding us, previous performance is no guarantee of future results! If you had a child previously, this only denotes that you were fertile that time – this can be no promise that a new problem might not have cropped up in the meanwhile which is causing you to become infertile now! This is known as secondary infertility – and is usually is much more annoying, since it is absolutely unexpected.

3. I can easily conceive, therefore i do not have fertility problems. I basically have miscarriages

An extended meaning of infertility includes woman who have repetitive pregnancy failures (miscarriages) – ladies who can’t carry the pregnancy to term. This is because the outcome in both the cases is the same – not being able to have a child to adore and to hold.

4. I am just too young to possess fertility problems!

Regrettably, infertility doesn’t care how old you are! While it’s true that older females possess a significantly higher possibility of being infertile, as they have “older” eggs, young females may also be infertile for a lot of reasons – for example damaged tubes.

5. My gynec told me that I don’t need to visit any fertility expert unless I have 3 miscarriages.

A miscarriage takes place in around 10 percent of all pregnancies. Since this is this kind of a common event, and frequently takes place for random genetic causes which usually do not recur, many doctors will not evaluate women who have experienced only 1 miscarriage. Not just is the assessment a waste of time and funds, it offers very little helpful information. This is the reason why the majority of physicians perform testing only when you have had at least two miscarriages. However, if you require further reassurance after experiencing a miscarriage, please ask your physician as to exactly what he or she can do in order to guide you.

6. I am fit. I work out on a regular basis. I cannot become infertile.

There is simply no connection in between your general wellness and your fertility. For instance, your fallopian tubes may be blocked without creating any kind of symptoms or indications. You have no method of knowing this, until you get them examined.

7. I am certainly not infertile. I am just not having enough sex.

This is a chance only when your lovemaking consistency is less than once a week. If it is much more compared to this, the probabilities of your having sex during your “fertile period” are usually quite high – you most likely will “hit the jackpot” at some period over the course of a year. Nevertheless, improving your love-making frequency is actually a simple (and enjoyable!) approach of enhancing your fertility. However, several women delude themselves and believe infrequent sex is the reason they are not having a baby, because they would rather deny the possibility of their having a medical problem for which they may need medical intervention.

8. Its fine to wait to have a child.

This is actually not a very good idea, for 2 reasons. First of all, if you have not conceived on your own in 1 year, the likelihood of your doing so on your own falls substantially. Secondly, fertility declines as an individual get older, and there is absolutely no point in losing time and decreasing your probabilities of success. Everything in life comes back again, except for time. It is a valuable, non-renewable resource – use it smartly!

9. Males cannot be infertile. They produce sperm regularly.

It is correct that males produce sperm all the time. However, around 10% of males tend to be infertile, simply because they generate poor quality sperm. Some possess no sperm in their semen at all – and there is no method of examining this without performing a semen analysis in the pathology laboratory.

10. Normal is a miracle.

Actually, this is true (just slipped it in to make sure you were paying attention!). When you think about how much precise synchronisation needs to be achieved for a good embryo to implant in the uterus to grow to be a baby, every birth is genuinely a remarkable feat – it’s remarkable how the individual body achieves this with such ease for so many couples!